HIV Can Be Spread in Beauty Salons, Despite UNAIDS Denial

An article about beauty salons in Georgia (the country, not the US state) makes it clear that HIV, hepatitis B and C and other serious viruses can be spread when good hygiene measures are not observed. Many salons, we are told, do not meet adequate standards. Customers are more interested in getting a good price than in avoiding health risks.

Perhaps people are not even aware of the risks, though. The article didn't manage to find any cases where serious infection had been confirmed to have come from a beauty salon. But if few people know about the risks, they are not likely to connect their infection with a visit to a beauty salon, which may have taken place years, or even decades before.

Even health professionals are unlikely to make the connection. When a HIV positive patient visits a health facility in most countries (I don't know if it's the same with Georgia), they are far more likely to be asked about their sexual history, with other risks given less attention, if any.

Adequate sterilization of instruments that may break the skin requires expensive equipment and good training and management. These may be absent in some salons. And all sorts of treatment can carry risks, not just manicure and pedicure but also male and female hairdressing, shaving and body piercing.

With a population of 10 times that of Georgia and a GDP per capita of less than one tenth, Tanzania must be in a far more dangerous position. There are many salons here, but price is even more important than it would be in a relatively rich and far more developed country.

In fact, the majority of poorer people in Tanzania do not go to salons for a lot of cosmetic work. The needs of many are attended to by friends and family with little or no training and even less access to sterilization equipment. Others go to the ubiquitous street cosmeticians, who will do your hands and feet out in the open as you wait for your bus or your friends or whatever.

UNAIDS doesn't even consider non-sexual transmission to be an issue when it comes to HIV in high prevalence countries. They insist that only around 2-2.5% of transmission occurs in health facilities. No mention at all is made of cosmetic or other non-sexual risks in the Modes of Transmission Surveys that I have seen for African countries.

It would be odd indeed if a country like Georgia were to be a risky place for such non-sexual transmission and a country like Tanzania (or Kenya, Uganda, South Africa, Swaziland and other high prevalence countries) were to be risk free. If people face sexual risks, they probably also face non-sexual risks. And that means they need to be made aware of these risks.

Non-sexual risks are recognised in some countries. A recent paper on the subject of hepatitis B in Pakistan notes "Lack of awareness, socioecomic conditions, sexual activities and sharing of razor blades, syringes and tattooing needles" as risk factors. And there, 21% of the population are infected with hepatitis B. Therefore, non-sexual risks in high prevalence countries need to be given as much attention as sexual risks.

[I should have mentioned that the Pakistan study is about Internally Displaced Persons (IDP), a group that is not representative of the population as a whole. National hepatitis B prevalence is estimated at about 67.5%, far higher than in the study population. In African refugee and IDP camps, HIV prevalence is usually significantly lower than in the population as a whole. Risks are clearly lower, although these camps are said to involve many hazards.]

Any exposure to blood, pus and other bodily fluids could carry the risk of serious disease transmission, especially where viruses like HIV and hepatitis are endemic. Teaching people only about sexual risks when serious non-sexual risks are being faced by everyone in a population, sexually active and non-sexually active people alike, is allowing some of the most easily prevented instances to continue, uninvestigated and unhindered.

UNAIDS have a standard excuse when non-sexual transmission is mentioned. They feel that it could deflect attention from sexual transmission. But if people face both sexual and non-sexual risks, UNAIDS are failing in their duty to give people accurate information that could protect them and their children. We will not protect people from HIV by lying to them about the risks they face.

Paid to Fail: the Politics of HIV Research

I recently commented on a much hyped but relatively vacuous paper by Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure, Benedikt and Gregson, entitled 'A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?'

But there was one item in the paper I didn't comment on that has stuck in my mind since. They write: "Many men in focus groups and interviews reported that having less disposable income has increasingly led to reduced ability to purchase sex or maintain multiple sexual relationships".

The sentence sounds reasonable enough if you accept the overall conclusion of the paper, that changes in sexual behavior driven by fear of HIV infection resulted in massive reductions in HIV transmission. But the data used by the paper only shows minor changes in sexual behavior. In truth, correlations between sexual behavior and HIV transmission are as unconvincing as they always have been, in Zimbabwe and elsewhere.

But even thinking about this sentence from an economic point of view and the little we know about commercial sex, does having less disposable income necessarily result in a reduced likelihood of purchasing sex? I think the real worry when money becomes scarce is that those who depend on providing sexual services for money have to settle for less money or provide more and/or riskier services.

Of course, such hypotheses need to be tested and many HIV researchers are reluctant to carry out rigorous research into sexual behavior. If sex turned out to be less relevant to HIV it's likely that funding would dry up. And if HIV prevention turned out to be a matter of providing decent health care, those currently selling drugs would also quickly lose interest.

There must be a lot of money in providing safe health care but it doesn't seem to attract the donors. But then, it's important to sell HIV drugs to developing countries because that's where the bulk of the market is. The same can't be said for other health care goods and services; not yet, anyhow.

Another problem with the idea that commercial sex becomes less common when money is scarce is that you'd think the trend for wealthier people to be infected in greater numbers than poorer people would reverse. This trend has reversed in some countries, but not noticeably as a result of economic changes.

The authors of the paper in question put a lot of credence in focus group discussions and that seems unwise. But it's their analysis of those findings that seem most disingenuous. The analysis appears to be independent of the data on sexual behavior, probably because the data is the same in high prevalence countries as it is in low prevalence countries. It's almost as if they are saying "here's the data, it contradicts our conclusions but everyone knows our conclusions are true anyway".

Because this paper doesn't even give a convincing pretense of having any substance, I'm still wondering what is behind it. The authors are very well established so the only reason I can think of that they would put their names to such rubbish is that they know no one really cares how they come to their conclusion as long as they come to the approved conclusion. But it seems like an expensive and circuitous way of failing to reduce HIV transmission.

Researchers Have No Opinion On Nosocomial HIV Infections in Zimbabwe

Non-sexual HIV transmission, when it's even discussed by the HIV orthodoxy, is usually dismissed with little argument and no evidence. What is most extraordinary is that one could hypothesize that both sexual and non-sexual transmission contribute to most epidemics and then try to work out the relative contribution of each. But they don't tend to do that.

Halperin, Mugurungi, Hallett, Muchini, Campbell, Magure, Benedikt and Gregson toe the party line in their recent paper 'A Surprising Prevention Success: Why Did the HIV Epidemic Decline in Zimbabwe?' They barely even mention non-sexual transmission and completely dismiss its significance.

But they do come to a very media friendly and quotable 'conclusion', that "fear of contracting the virus [is] the primary motivation for changes in sexual behavior". Journalists have pounced on this 'finding' and will continue spreading it for some time. Perhaps these researchers have recognized the value of media friendliness and found it to be more congenial than credible, enlightening research that could turn around the HIV pandemic.

Despite constant boasts about the number of people on antiretroviral treatment and the idea that you can contain an epidemic by throwing lots of drugs at it (which happens to be the current global treatment policy), these researchers even mention the very real possibility of drug resistance making mass treatment campaigns less sustainable than they currently are. They are in good company; Bill Gates recently said more less the same thing.

But what was their quotable conclusion based on? Well, they did a bit of mathematical modelling and read a few papers written by like-minded people (actually, the bibliography overlaps considerably with the list of authors), but they also give a lot of credence to a bunch of 'stakeholders', who certainly seemed to do a fair amount of agreeing with each other. Perhaps they see this as quantitative, their credence, the stakeholders' agreement, etc.

It's odd, when people say they have never had sex, never had unprotected sex or never had sex with anyone other than their partner (who is often HVI negative), they are unlikely to be believed, especially if they are African. But if they are like-minded people holed up in a hotel, their responses are treated at face value.

"[T]he unanimous conclusion from the stakeholders meeting held to assess, triangulate, and interpret the evidence assembled in the review was that a reduction in multiple sexual partnerships was the most likely proximate cause for the recent decline in HIV risk." What a surprise.

It goes on: "In assessing the underlying factors for the national prevalence decline, high AIDS mortality appears to have been the dominant factor for stimulating behavior change." Yet, high AIDS mortality has been a phenomenon in many countries that have had very high HIV prevalence. When lots of people become infected, lots of them die, widespread treatment regimes notwithstanding.

Similar claims used to be made about Uganda, though these researchers are also keeping Uganda at arm's length. Well, it's almost certainly true that some people were devastated by what they saw around them when huge numbers of people were dying terrible deaths. That would have some impact on anyone.

But the idea that it would be almost entirely responsible for levels of behavior change that resulted in a massive drop in rates of new infections in a short space of time in Zimbabwe, but nowhere else, is not credible. Nor is it even necessary to make such a foolish claim.

The economic decline experienced in Zimbabwe in the late 90s and early 2000s, we are told, played a considerable secondary role in amplifying patterns of behavior change. No doubt it did. But economic decline could also have resulted in fewer visits to the country's deteriorating health facilities, which would have reduced the number of nosocomial infections (infections resulting from medical treatment).

And what levels of behavior change occurred? From the figures cited, age of sexual debut and condom use barely changed. And multiple partnership indicators improved a bit, but these were never common enough to explain the almost umprecedented rates of transmission once found in the country. Most of these indicators wouldn't even look out of place in rich countries.

Interestingly, the researchers mention "the Zimbabwean government's early adoption of a home-based care policy [which] may inadvertently have accelerated the process of behavior change. It has been hypothesized that, when people die at home, this direct confrontation with AIDS mortality is more likely to result in a tangible fear of death among family and friends than when patients are primarily cared for in clinical facilities, such as in Botswana"

I'd interpret the effect of this policy rather differently. It could also have taken a lot of HIV positive people out of a health system that was not able to provide people with safe healthcare.

The authors conclude that significant changes in behavior are unlikely to have resulted from increasing levels of mortality alone. They also suggest that prevention programs provided people with information about the link between risky sexual behavior and HIV transmission. And they are probably right, to an extent. But why were these programs so successful in Zimbabwe when they failed so miserably elsewhere? The authors bluster on, unconvincingly.

Indeed, they don't even seem that convinced themselves. They can't really put their finger on anything much so they talk about "cumulative exposure" to prevention messages, as if that wouldn't have happened elsewhere. Similar claims have long been made to "explain" what happened in Uganda. After all, there must be some explanation, and if it has to be about sex this one is as good as any other.

I can understand a whole group of stakeholders churning out answers that would satisfy even a UNAIDS employee about the drivers of HIV. I have met few people who wouldn't say similar things. But I don't believe the authors could look on this this paper as a publishable piece of research. If they are all happy with it, then I am disgusted. Their own research screams for investigation of non-sexual transmission levels, but they carry on regardless.

Flawed HIV Transmission Models Beget Flawed Strategies

A researcher called Jeremy R Magruder has written an interesting thesis about 'marital shopping' or 'spousal search' patterns being behind high and medium prevalence HIV epidemics in African countries. According to his model, when people are searching for a partner, they have unprotected sex with several different people in a relatively short space of time.

The factor that really increases the probability of HIV transmission is that people who have recently been infected are most infectious. Their HIV positive status may not even be detected by tests, so regular testing would be unlikely to help much. Therefore, this brief period of rapid partner change is likely to result in more transmissions than other scenarios.

This model is interesting because Magruder suggests that advising people to use condoms for the first three months of a new relationship could provide very high levels of protection. Better still, evidence has suggested that people respond better to behavior change strategies that are more feasible.

Unsurprisingly, being told to abstain for an indefinite period, even if it is until marriage, is a lot less feasible than abstaining until the end of secondary school. And using condoms for a few months into a new relationship is a lot more feasible than using condoms, not just until marriage, but throughout marriage.

Magruder also notes that efforts to reduce sexually transmitted infection prevalence and male circumcision are unlikely to have much effect on transmission rates. He even dismisses the benefits of looking at antiretroviral treatment as prevention, something some technology fanatics have suggested as their magic bullet of choice.

But the model becomes less credible when you start to ask why prevalence in some African countries is only 1%, in others it is over 5% and in the worst affected countries it is over 25%. Prevalence is over 40% in some demographic groups and many people who never have sex, or who always use protection, are also infected.

Within countries, prevalence also varies greatly, with less than 1% in some areas and figures that are 10 or 20 times higher in other areas. Variation between tribes can be equally high and the ratio of male to females in some tribes range from 17% to 120%. Could this really be explained by differences in spousal search patterns?

Magruder could explain these differences by reference to differences in levels of 'unsafe' sexual practices or in levels of protective behavior. But this is one of the great mysteries of sexually transmitted HIV: transmission rates can be higher among those who practice 'safe' sex. Attested levels of safe and unsafe sexual practices don't correlate with HIV prevalence.

Also, is Magruder suggesting that spousal search patterns changed some time in the 1970s and 1980s, a phenomenon which might explain why the virus was spread so rapidly during this period and not before? And is he suggesting that this search pattern changed again some time in the 1990s, when HIV incidence, the yearly rate of new HIV infections, peaked and declined in most African countries?

Magruder has assumed the truth of a version of the behavioral paradigm, the view that HIV is almost always transmitted sexually. He simply ignores the possibility that some, perhaps a lot of HIV, is transmitted non-sexually.

But Magruder doesn't subscribe to the view that African people engage in inordinate amounts of sex with little concern for the consequences for themselves or their families. And that is refreshing. But it may not help him gain acceptance for his thesis. The HIV orthodoxy is very committed to its racist and sexist views of HIV transmission.

Magruder may have shed some light on how sexually transmitted HIV could be spread by people who are only human and can only engage in humanly possible levels of sexual behavior. But until some light is also shed on what proportion of HIV is transmitted sexually and what proportion is transmitted non-sexually, his strategy will bring only limited benefits.

Global HIV/AIDS Policy for Africa: Mass Denial of Human Rights

Rumor and myth continue to dominate academic writings about HIV/AIDS, especially when it comes to explaining why HIV prevalence has declined in many countries which have experienced a very serious epidemic. In brief, HIV academics don't really have a clue why the virus spread, peaked and declined in the first place. Therefore, they don't know which prevention programs work and which don't. Some of them may have worked, or they may just have appeared to work because they began shortly before the high death rate stage of the epidemic.

Leaving aside the somewhat risible strategies of abstinence and partner reduction, which were never as vital as the literature claimed, nor as successful, that leaves the one strategy that could have had some impact on sexual transmission of HIV. Using condoms could have been successful if people used them, consistently. But in most places, they didn't. Many people have used condoms, some even use them several times a year. But this is not enough to have much impact on sexual transmission.

A fairly typical set of results comes from Kilifi, in Kenya's Coastal Province. The "mean number of condoms used was 2.2 per person per year among all sexually active individuals". Usage was lower in rural contexts. The majority of people in all East African countries live in rural areas. And not only is condom use lower in rural areas, so is HIV prevalence. There is more than a hint that the extent to which HIV is a mainly sexually transmitted virus has been seriously exaggerated.

Uganda is one of the few countries credited with playing an active part in reducing HIV transmission. The country may have achieved all sorts of feats, it's hard to tell, because rates of transmission there peaked and declined just as mysteriously as they did in other countries. It's just that in Uganda, the epidemic arrived, spread, peaked and declined earlier than it did in Kenya, Tanzania and most of the very high prevalence countries of Southern Africa.

Knowledge about condoms, HIV, unplanned pregnancy and other matters is not nearly as widespread as all the hype suggests. People in urban areas, people with better education and people in higher income brackets know a lot more than people in rural areas. HIV rates being higher in less isolated areas and lower in more isolated areas tends to make popular reduction strategies look a bit pointless.

But I wouldn't like to suggest that higher condom use or knowledge about sex, sexually transmitted infections, unwanted pregnancy, etc, are associated with higher HIV rates, just that they are not particularly relevant to HIV rates. Nor is it to suggest that using condoms to reduce HIV transmission, the transmission of other sexually transmitted infections and unplanned pregnancies is not a good thing.

It's just that HIV is not, as UNAIDS and other 'experts' keep claiming, almost always heterosexually transmitted in African countries (but not in non-African countries). WHO admits on their web site that up to 14% of infections may be spread by unsafe injections and they have unpublished data that suggests such infection rates are even higher. As for the proportion of HIV transmitted by other non-sexual routes, none of these authorities have bothered to check yet.

Given the rates of transmission among intravenous drug users, men who have sex with men and mother to child transmission, the proportion of HIV transmitted through heterosexual sex is in urgent need of investigation. Otherwise there is a danger that these highly inefficient, expensive and deceptive 'prevention' interventions will continue to deflect attention away from the health services that may be causing more infections that they have ever been able to prevent.

A recent paper shows that 50% of the 500,000 people currently infected with HIV in Uganda are under 25. The study also shows that young people know very little about sex, condoms, HIV or pregnancy, despite the hundreds of millions of dollars that have been spent. HIV rates in the area are high. Sadly, young people appear to have picked up many of the rumors spread about condoms by religious leaders, journalists and others who seem to prefer to maintain high rates of STIs and unwanted pregnancies (and the consequent high rates of unsafe abortions).

Firstly, young people need sex education and it needs to be an integrated part of their overall education (not an afterthought tagged on to an already under-resourced system). If religious and political leaders are hell bent on filling people's heads with rubbish (in addition to the bunch of lies they get from the HIV industry), at least with a good education they have some chance of working things out for themselves.

But their education needs to include information about non-sexual HIV transmission routes, such as unsafe healthcare, unsafe cosmetic practices and perhaps some traditional practices that involve exposure to contaminated blood. And in order for this information to be of any use, people need accessible and safe healthcare.

Countries with continuing high rates of HIV transmission can not afford to depend on luck. It is lucky that HIV transmission rates declined. But current rates of transmission are still too high. The HIV industry harping on about sexual behavior and the religious and political interests contradicting every piece of advice given is not going to lead to a reduction in current rates of transmission. As Uganda and other countries are finding, HIV rates can also start to rise again.

In places where very little HIV is transmitted non-sexually, fine, as long as steps are taken to eradicate these forms of transmission altogether. However, it looks as if non-sexual transmission is far from trivial in most African countries. This is in urgent need of investigation and this work can take place at the same time as the work on sexually transmitted HIV. But ignoring non-sexual transmission is probably doing more to spread HIV than continuing the many failed sexual prevention interventions.

The consequences of the lies and inaction from UNAIDS, many HIV/AIDS academics and various institutions are almost too terrible to contemplate. But we can not allow this mass denial of human rights to continue.

For the New Year; Less Talk About Sex, More About Unsafe Healthcare

Doug Kirby is only one in a long list of people to speculate about Uganda's 'success' in reducing HIV transmission from relatively high rates in the 80s and 90s to relatively low but steady rates in the 2000s.

As he and others wonder what happened, some sceptics have doubted if Uganda did anything in particular and have even suggested that the epidemic may have arrived, spread and declined, almost entirely independently of anything that was done to prevent it.

A lot is made of the so called ABC program (Abstinence, Be faithful, use a Condom), as if all HIV is transmitted sexually. It isn't, it never was and at one time, even in Uganda, this important fact was acknowledged.

Anyhow, no one working in Uganda in the 1980s and 1990s remembers the term ABC, it appears to have been invented later, and not even in Uganda. Also, no one seems to remember the sheer idiocy of an 'abstinence only' program, either in name or in nature. But let's indulge in Kirby's apparent sincerity as he speaks for the majority of HIV researchers.

The notion of abstinence is inherently vague; is it to abstain from sex for ever, to abstain until marriage (one of the senses used by Demographic and Health Surveys), to abstain for a period (such as during the day during the course of Ramadam), to abstain from certain kinds of sex, to abstain from sex with one's main partner, to abstain from sex with those other than one's main partner, to not have had sex for the past week/month/year, etc.

Knowledge of ABC as a whole is also deceptive because it clearly doesn't lead to the expected behaviors and HIV rates are often higher among those who appear to have higher levels of knowledge about 'safe' sex. In Tanzania, for example, knowledge is higher among wealthier, better educated, urban dwelling, 20-39 year olds, but so are HIV rates.

Indeed it has never been shown that people with the 'requisite' knowledge are less likely to be infected. In fact, those with the requisite knowledge appear to be more likely to be infected. This is not to suggest that knowing what they are taught about HIV puts people at higher risk. I am suggesting that this 'knowledge' is just not particularly relevant and it leaves out things people really need to know, such as details of non-sexual risks and how to avoid them.

None of these 'methods' of reducing the chances of being infected with HIV really amount to much. So they couldn't explain how Uganda's epidemic declined. They might have contributed a little but it's impossible to say how much. They are not really testable. They are simply based on the incorrect assumption that almost all HIV is tranmsitted sexually in African countries, so if people don't have sex, they won't be infected.

Education is a right that need have no connection with HIV or any other disease. As it happens, better educated people usually enjoy better health. But there is no useful list of causal connections between education and health. Sex, sexuality and reproduction education are also rights, but a reasonable level of general education is a prerequisite in order for people to be well educated about these issues.

Lack of knowledge about sex, sexuality and reproduction is likely to cause many problems. People growing up in ignorance of such issues face many risks, such as sexually transmitted infections, unwanted pregnancies and possibly emotional and psychological problems.

But when it comes to HIV, this area of education is not enough. People also need to know about non-sexual risks, faced in cosmetic and hairdressing facilities, tattoo and body piercing parlors, traditional healing and related contexts and, most importantly, in health and medical facilities.

If people don't know about non-sexual risks, they will not know how to take steps to avoid them. They will not know enough to check if the hairdresser sterilizes their equipment adequately, that some processes are better avoided if their safety is unknown and that in underfunded, understaffed, undersupplied health facilities, you have to check that the equipment being used is sterile, whether that equipment is new and unused or reused but properly sterilized.

If none of these measures are taken regarding non-sexual HIV transmission, no number of condoms delivered, sexual experiences foregone or anything else will guarantee protection against HIV (and other viruses, such as hepatitis B and C).

Uganda may have taken some of these precautions against non-sexual HIV transmission in the early days of the epidemic. Doug Kirby doesn't mention them much, but that doesn't mean they didn't occur. But the health access situation in Uganda is quite similar to those in Tanzania and Kenya. Most people don't have access to health services and when they do, the quality is low. But as health services spread, or as people move to access health services, HIV also spreads.

In contrast, in Southern African countries, far more people can access health services. Unfortunately, those health services are also of very low quality. So the chances of being infected in health facilities is even higher in Southern African countries. Therefore, it is unlikely to be a coincidence that Southern African countries have the highest HIV rates in the world.

Of course, I could be completely wrong, Perhaps UNAIDS are right that only 2-5% of HIV transmission comes from unsafe healthcare. Or WHO may be right that only 15-20% of transmission comes from unsafe healthcare. What I would like to see is proper investigation of health care facilities and a credible estimation of what proportion of HIV is being transmitted non-sexually (not just in health care facilities, but also as a result of traditional practices, cosmetic practices and anything else that may be involved).

We have been very unsuccessful in influencing sexual behavior and this lack of success may continue. But providing people with affordable and safe healthcare would not be nearly so elusive. And people have the right to know what the major non-sexual HIV risks are and how to avoid them. Up to now, Africans have been treated with utter contempt and, as a result, millions have been infected with HIV. Many have died and many more will die, despite all the money being churned into antiretroviral drugs.

No Leap of Faith Required to Question HIV Orthodoxy, Just Honesty

Many millions of words have been dedicated to what was said to have happened in Uganda in the 1980s and 1990s that resulted in a serious HIV epidemic peaking and declining dramatically.

Well, for a start, all the high figures cited for HIV prevalence in Uganda in the early days of the epidemic are for specific groups, such as pregnant women. Prevalence for the whole sexually active population at that time is rarely given and is probably not clear, even now.

Once more detailed prevalence figures were established for later periods in the epidemic, it became clear that there had long been more women infected than men. This should have resulted in questions about who infected all these women.

But HIV professionals don't ask such questions because they don't fit the 'behavioral paradigm', the view that HIV is almost always transmitted sexually in African countries (but not in non-African countries, go figure). They are content to talk about how low the prevalence figures are now, though they are nothing to boast about.

So the 'dramatic' drops in HIV prevalence, from double figures to single figures in a few years, never occurred. What drops in prevalence did occur would mostly have been down to very high death rates.

All the talk about behavior change was mostly just that, talk. Some behavior change may have occurred, probably as a result of people witnessing massive levels of sickness and death, but this would have been after incidence rates had already peaked and declined.

Why incidence rose so rapidly in the 1980s and perhaps before, and why they peaked and declined, is not clear. At least, it's not clear if you accept the behavioral paradigm. There is no evidence that 'unsafe' sexual behavior inexplicably increased in the late 1970s and early 1980s and then declined again before the end of the 1980s.

Unless there was some identifiable change in levels of sexual behavior that led to barely credible feats of promiscuity in Uganda some years before the HIV epidemic peaked, it remains a mystery why the epidemic ever infected so many people.

And it's not just in Uganda that there remains this mystery. The massive rise in promiscuity that occurred there must have taken place a few years earlier in Western Equatorial countries, where HIV had been a less serious epidemic for even longer. Sometimes it becomes more of a mystery to explain why some places in Africa never experienced this strange phenomenon.

Anyhow, this totally unrecorded rise in promiscuity must have taken place in Tanzania a bit later than it did in Uganda. In Kenya it must have taken place a few years later still, because incidence there increased and peaked a few years later.

Then Southern African countries experienced this same unrecorded and mysterious increase in promiscuity that barely affected Western and Northern African countries at all.

Outside of African countries, no wave of promiscuity was needed to explain serious HIV epidemics because this virus which is said to be spread predominantly through sexual behavior in African countries is accepted as a virus that spreads most efficiently through unsafe injections among intravenous drug users and among men who have sex with men.

That's the way the behavioral paradigm goes, anyhow. It claims that Africans have inordinate amounts of unsafe sex and that different African countries at different times experienced enormous increases in unsafe sexual behavior that 'explain' the resulting difference between low HIV prevalence countries such as Senegal, medium prevalence countries such as Uganda and high prevalence countries such as Swaziland.

The original question about what 'happened' in Uganda, prevention interventions and the like, was if the same thing could occur in other countries. Well, the same thing didn't occur in other countries, according to the official story. Outside of Uganda, most governments denied the existence of HIV or ignored the epidemic. Very few leaders were in any way open about HIV in their own country.

Despite this, most medium and high prevalence countries have followed a similar epidemic pattern to that found in Uganda: HIV arrived and spread rapidly, peaked and declined. Since the initial decline, infection rates have continued at a relatively low rate, as have death rates.

But all this appears to have occurred independently of anything the respective governments did or didn't do. Whether governments reacted to the epidemic or ignored it, roughly the same pattern resulted.

So, the two things the behavioral paradigm encourages us to believe are different but not wholly compatible: firstly, the paradigm paints Africans as grossly promiscuous and unconcerned about their own health or the health of their children.

And secondly, when called upon to explain the original increase, peak and deline in HIV infections, the orthodoxy makes up a story of a promiscuous people (because all Africans are the same under this paradigm) becoming even more promiscuous, because of urbanization or some other factor that may have little or no explanatory power.

We are then left with the problem that the Senegalese and people from various other low prevalence countries have never really been particularly promiscuous. And even some tribes in a country like Kenya have less sex than others. The Luo, with high HIV prevalence, according to the paradigm, must have a lot more 'unsafe' sex than the Somalis, who have low HIV prevalence (despite having the highest fertility rates in the country).

If we accept a sexual explanation and follow the argument through, we still have to tie ourselves in knots. What gave rise to an epidemic of promiscuity that eventually resulted in a serious HIV epidemic in only some parts of some countries?

It's way past the time for HIV 'experts' to accept the fact that HIV is spread both sexually and non-sexually and that when it can't be adequately explained by normal sexual behavior, found in every country in the world, that something other than sexual behavior must be involved.

No leap of faith is required to question the HIV orthodoxy; all that is required is a bit of honesty and integrity. I don't think that's too much to ask but, we're still waiting.

Academics Can Not Be Trusted to Tell the Truth About HIV

Until HIV academics lose their obsession with sex, HIV epidemic patterns will continue to be misrepresented, giving instead a seriously biased picture. This bias does not just have consequences for academic papers; it translates into biased policy, biased intervention programs and biased reporting. As a result, HIV continues to infect and kill millions of people, unchecked by those who are supposed be best placed to control the epidemic.

Doug Kirby had an article a couple of years ago entitled 'Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence'. The 'conclusion' that sexual behavior was behind all African epidemics is not really the issue here; that is something of a reflex.

The issue is about 'confirmation' from 'multiple' sources of evidence. In a nutshell, the paper does not lend confirmation to the behavioral paradigm, the belief that HIV is almost always transmitted sexually in African countries. Nor are the 'multiple' sources of evidence wholly independent of each other.

The fact that adherents of the behavioral paradigm have persuaded most of those working in the field to sing from the same hymn sheet does not have the effect of strengthening the evidence.

The reason all this talk about sexual behavior in Uganda does not confirm the behavioral paradigm, during the 1980s or any during other period,  is that it simply ignores non-sexual HIV transmission. People are rarely asked questions about anything but their sexual behavior, knowledge and attitudes. And yet it is thereby concluded that only sexual behavior, knowledge and attitudes are relevant.

Kirby's article even mentions that people were "more careful in general, avoided people with AIDS, were careful with blood, were careful with injections, etc." This glosses over what may be useful evidence about non-sexual HIV transmission.

But this was in 1989, when it was still acceptable to mention non-sexual HIV transmission. Not long after that it ceased to be acceptable. People were rarely asked about anything but their sexual behavior, knowledge and attitudes. Therefore, there is little data available. And this article, like so many others, skates over anything that is not about sex.

In fact, Kirby's point seems to contradict his thesis: the majority of people had made no change in their behavior or merely intended to make changes. Only a small minority had actually made changes. Not only is there little evidence that sexual behavior change was likely to have any impact on the epidemic, that relevant behavior change actually occurred and had any impact on the epidemic, or that it will ever have a substantial impact on the epidemic anywhere, but the whole paper assumes the truth of its conclusions, despite the paucity of evidence.

As for the 'multiple' sources of evidence, newspaper articles published whatever the going story was at the time. This would have been influenced by a mixture of half-baked policies, misinformed pronouncements and a handful of 'academic' papers that happened to suit the current buzz around AIDS.

The focus groups and other qualitative data is likely to have been heavily influenced by the same media buzz. In other words, most people would have been remembering what they heard, read and talked about as much as by what was happening, which was and continues to be largely misunderstood.

'Models' of what was happening, especially when the figures came from ante-natal clinics and STI (sexually transmitted infection) clinics tend to be somewhat circular. These facilities would have had very high figures for HIV infection because they were established to deal with the epidemic. In addition to the fact that figures from these facilities could not be generalized (although they were and sometimes continue to be), it is likely that many people were infected in health facilities through unsafe medical procedures.

It is not much talked about now and when it is, it is usually talked about as if it doesn't happen any more. But in the eighties especially, and sometimes in the 1990s, HIV was not just seen as an STI. It was also seen as a virus that was spread through various medical procedures. Blood transfusions were one of the most prominent medical procedures because the probability of transmission through contaminated blood was extremely high.

But most people don't receive blood transfusions. What most people do receive are injections and various other procedures which carry a high risk of transmission if equipment is contaminated. The risk is nowhere near as high as it is with transfusions but it is orders of magnitude higher than it is for sexual transmission, the probability of which is quite low per sex act.

Articles like Kirby's simply leave non-sexual transmission out of the picture. What proportion of various country epidemics are down to non-sexual transmission is unknown. What is known about sexual transmission is impossible to evaluate because we have little idea what proportion of overall transmission it accounts for.

Indeed, it is no secret that sexual behavior can not really explain why some countries and parts of countries have inordinately high HIV prevalence. But those who take the behavioral paradigm as their starting point still make up the majority among HIV academics.

Exactly why academics have continued to present this biased view of HIV epidemics is really not clear. Surely the desire to appear to be right, now that thay have been painting themselves into this corner for so long, cannot explain why so many millions of people are being condemned to avoidable sickness and death? But that doesn't really solve the problem of how to change this situation.

It appears that academics can not be trusted to tell the truth. They are not content to research, analyze and report unless their writings conform to what amounts to a dangerously biased orthodoxy. Will they continue to lie until their consequent irrelevance becomes widely recognised? Or will we simply let them get on with not doing their job while innocent people, women, men and children, suffer the consequences?

Kirby claims to have no competing interests but some of the funding was supplied by UNAIDS, that great bastion of the behavioral paradigm and attacker of anyone who suggests that HIV is not all about sex. Kirby also mentions help from Daniel Halperin, which would also have ensured that the conclusion wouldn't shock or offend anyone in the orthodox camp by reducing bias or acknowledging any of the more serious limitations of the study.

Anal Sex Can Be Dangerous But Likely to Be Ignored in African Countries

Ostensibly, Kenya's Modes of Transmission Survey aims to establish what factors are driving the country's HIV epidemic. I say 'ostensibly' because there are two glaring figures that cast doubt on all the other figures. The first is the figure for men having sex with men (MSM), which is lumped together with HIV in prison populations. The second is the figure for health facility related infections, which, at 2.5%, is extremely low compared to WHO figures for unsafe injections alone, which could be 8 or 9 times higher.

However, I've mentioned health facility related infections on many occasions, so I'll concentrate on MSM on this occasion. Prison populations would be at risk of HIV transmission through heterosexual sex, like everyone else. But more importantly, those infected through intravenous drug use are more likely to be in prison, given that the practice is a crime. Those in prisons may also be more likely to be infected through tattooing, taking blood oaths and, arguably, through unsafe healthcare.

That puts the provenance of one third of Kenya's HIV infections in serious doubt, the proportion either claimed to be or suspected of being from MSM and/or unsafe healthcare. The fact that another half of infections are said to come from relatively low risk sex makes the Survey seem like a pretty blunt instrument. But anal sex, whether homosexual or heterosexual, is known to be high risk sex. And, despite the need to target MSM, it is completely unclear what proportion of people engage in this practice.

What is clear is that MSM (and others engaging in anal sex) are not targeted particularly well. For a start, the practice is illegal and the country's Prime Minister Odinga recently called for the arrest and imprisonment of all practicing homosexuals. As a result of such attitudes and outbursts, who Kenya's MSM are and where they are is not only unclear, but likely to remain so.

Given these circumstances, it's not surprising that a survey of male sex workers providing services to men in Mombasa found that 35% of respondents did not know that HIV can be transmitted through anal sex. It is therefore unlikely that heterosexuals are aware that anal sex is an efficient transmitter of HIV, regardless of the gender of those involved, or that it is far more dangerous for the receptive partner.

Just over 20% knew that a water based lubricant should be used with latex condoms and again, it seems unlikely that heterosexuals engaging in anal sex are any more likely to know this. They are probably less likely to be targeted with correct information, despite evidence that many people think that anal sex does not transmit HIV at all. Even if people knew, they would be unlikely to find an appropriate lubricant easily. Many are said to resort to household products, some of which are more likely to weaken condoms than reduce the risk in any way.

Odinga, the Modes of Transmission Survey and the current calls for homosexuality to be punished even more severely than it already is suggests that Kenya is more interested in pointing the finger than in dealing with serious problems that are not just going to disappear. After frittering away tens of millions of dollars of donated HIV funds, Kenya was refused funding on several occasions.

And now, despite the continued lack of transparency, the Global Fund has decided to give the country nearly 40 billion Kenyan shillings in funding. The Global Fund, going by its title, is earmarked for HIV, TB and malaria, rather than for health systems or infrastructure. So its effects are going to be limited.

But ignoring risky sex (along with most non-sexual modes of transmission) and concentrating mainly on those who don't engage in risky sex seems like completely the wrong way to go about things. For a start, let's stop pretending that the majority of people are at risk of being infected sexually and find out why people engaging in low risk sex seem to be the largest contributor to Kenya's HIV epidemic.

The least we can ask of the Global Fund, then, is that even if they are not prepared to spend anything on non-sexually transmitted HIV, they should seriously consider targeting those who are genuinely at risk of sexual transmission: MSM and sex workers, and perhaps some others.

Mass Male Circumcision; a Motiveless Crime?

Some of the staunchest advocates of mass male circumcision (MMC) as a means of protecting men from infection with HIV, and even herpes simplex virus (HSV-2), have found that the operation is unlikely to have very much effect. Many years of 'research' has been carried out on how to ram MMC down the throats of male members of the Luo tribe in Kenya's Nyanza province.

There has never been much convincing evidence that MMC would be effective in the first place, but circumcision advocates don't seem bothered by that. And the more certain it is that MMC will not do any good, that it may even do a lot of harm, the more enthusiastic advocates become. In fact, this data was collected before large numbers of Luo men were circumcised (or were claimed to have been circumcised, actual numbers are hard to come by).

This particular piece of research found extremely high HIV (and HSV-2) prevalence; 17% among males and 26% among females. Rates for both viruses were similar for circumcised and uncircumcised males. Rates like this contrast strongly with those found in the rest of Kenya, with national prevalence standing at 6 or 7%. The second highest male prevalence rates, found among the Maasai, are about half those found among the Luo.

Those promoting circumcision have not explained the huge differences between tribes in HIV prevalence rates. There are even anomalies such as the extremely high rates among female Luhyas (12%) when rates among male Luhyas are relatively low (1.9%).

In short, HIV rates are high among the Luo, many of whom are not circumcised. But circumcised Luos have equally high HIV rates. So why insist that lack of circumcision explains why members of this tribe have such high HIV rates? And why insist on MMC when this is obviously not going have much positive impact on transmission rates and may have a negative impact?

The research also shows that people have been hoodwinked by the hype that MMC has received. Men think they are less likely to be infected with HIV if they are circumcised and women think circumcised men are less likely to be HIV positive. What most people don't seem to realize is that the 60% protection that circumcision arguably imparts requires that condoms are also used.

But if condoms are used, uncircumcised men are also protected. The operation is not only possibly useless and potentially harmful but it is also completely unnecessary, even for those who think it may protect them. They could just use condoms.

The research notes that "Uncircumcised men who preferred circumcision were more likely to report inconsistent or no condom use, describe sexual partners as ‘casual’, and report current/recent genital ulcerations" and that these men may 'self-select' for an MMC program. The authors see this as a good thing but I would question their analysis of this finding.

Other research suggests that many men and women think male circumcision will protect them from HIV and that they don't need to use condoms. Even people who can give the 'correct' answers to questions about HIV and circumcision, as a result of having them drummed into their heads, seem a little too anxious to embrace an intervention which is not well understood (by them or anyone else).

Recommending, and even carrying out, an operation that is clearly unnecessary and possibly hazardous sounds distinctly unethical. Failing to establish why HIV transmission rates are so high among the Luo after so many years of research is bad enough, but it certainly does not support the contention that what Luos need is MMC. Having said all that, I am unable to supply a motive for the behavior of circumcision advocates and would love to hear from anyone who could do so.

UNAIDS' Obsession with Sex Helps Spread HIV

According to an article in Tanzania's Citizen newspaper, there is 'growing concern' that HIV transmission is increasing among those in long term relationships and in marriages. Yet HIV prevalence has been high in these groups for a long time. Tanzania may not have carried out a Modes of Transmission Survey recently, as Kenya and Uganda have done. But the three countries have similar epidemics.

The advice that having sex with a long term partner or spouse will protect you from HIV has never been quite true. 'Safe' sex practices may include reducing the number of partners you have and various other measures, such as using condoms, avoiding sexually transmitted infections, etc. But HIV is not, and has never been, solely transmitted sexually. It is also transmitted through unsafe medical practices, such as unsterile injections, traditional medicine, cosmetic practices, such as shaving and tattooing and perhaps other means.

Telling people that they will be protected from HIV if they 'abstain' from sex or obey any of the other paternalistic strictures of the predominantly right wing 'Christian' prevention programs that dominate African country HIV strategies is extremely unethical. Since HIV was first identified, it was clear that it was mainly transmitted through contaminated blood. Sexual transmission was also recognised, especially through anal sex. But the risk of transmission through heterosexual sex was and is quite low.

People are entitled to know that if someone is HIV positive, this does not mean they are promiscuous. You can not tell how someone was infected with HIV without investigating, and even then, the exact cause may still remain unclear. It is worth bearing in mind that heterosexual sex is not an efficient transmitter of HIV. But contaminated blood is a very efficient transmitter.

Many people who are HIV positive are unaware of how they were infected and assume that because they are not virgins, they must have been infected sexually. However, they need to find out if their partner is infected. And even if their partner is infected, they may still not have been infected sexually. It's perfectly possible to be infected through unsafe injections, say, even though your partner was infected sexually.

It is vital that people are made aware of the risks they face and the steps they can take to reduce those risks. They need knowledge, skills and empowerment to be able to ask health and other professionals for evidence that they are observing all safety guidelines. This is necessary to ensure that neither HIV nor any other blood borne infections are transmitted during routine procedures. If people don't know about nosocomial HIV infection, infection through unsafe medical procedures, they will not be alert to the risks and will not take steps to avoid them.

It is heartening to hear that some have made the connection between exposure to contaminated blood and HIV transmission. A group in Kenya, and more recently in Tanzania, has recognised that HIV can be transmitted if care is not taken removing jiggers. This is often done using an unsterilized safety pin or other sharp object. If the object is then used on other people, there is a considerable risk of transmitting HIV and other viruses. Even if a virus is not transmitted, serious infections can result.

But despite small numbers of people in Kenya and Tanzania knowing that HIV is not just transmitted sexually, UNAIDS and others in the HIV industry are reluctant to accept the importance of non-sexual transmission. Official figures estimate that transmission through unsafe medical practices is very low. As a result, only a tiny fraction of the billions being ploughed into HIV prevention goes towards non-sexual HIV transmission.

Exactly why UNAIDS and the rest of the industry wish to ignore non-sexual HIV transmission is not clear. But the organization has always been pretty irrelevant to the HIV pandemic. With our without UNAIDS, people need to recognise the most common and the most serious risks they face. HIV is not just about sex and it has never been just about sex. Anything that involves exposure to blood or certain other bodily fluids can carry a risk of transmission of HIV and other viruses.

[For more about UNAIDS' and the HIV industry's obsession with sex, see my other blog.]

Prejudice Wins Over the HIV Industry

It has been well established that HIV is transmitted through sexual contact, through contaminated blood and other bodily fluids and from mother to child. However, UNAIDS and the HIV industry have a rather anomalous view of the disease. They have decided (or decreed?) that HIV is primarily spread through heterosexual sex in African countries (and from mother to child). But in other countries, so the story goes, HIV is primarily spread through contaminated blood, by intravenous drug users and unsafe medical practices, through men having sex with men and among commercial sex workers and perhaps their clients.

If HIV is mainly spread through blood-borne transmission, one would expect it to follow a similar pattern to other blood-borne diseases, such as hepatitis C virus (HCV). Two researchers have found that to be the case in a number of Asian countries. Countries with low HIV prevalence also have low HCV prevalence and countries with high HIV prevalence have high HCV prevalence. This means that countries with low HIV prevalence might see rates increasing at some stage in the future.

If HIV is mainly spread through heterosexual sex, as it is said to be in African countries, one would expect it to follow a similar pattern to other sexually transmitted infections. But this is not the case. Sexually transmitted infections are very high in many countries where HIV prevalence is not very high. Also, sexual behaviour that is said to increase the risk of HIV transmission tends to be a lot more common in countries that have relatively low HIV prevalence.

Differences between male and female sexual behaviour are also telling, where such differences have been detected by empirical enquiry, as opposed to speculation and assumption. Whereas males are more likely to engage in unsafe sexual practices, females are more likely to be infected with HIV. Men also tend to have more partners than women. But there is nothing to suggest that what is mainly a blood-borne disease in some countries should be mainly sexually transmitted, and rarely blood-borne, in others.

So, UNAIDS and the HIV industry are wrong in (at least) two important respects: firstly, it is unlikely that HIV is transmitted primarily through unsafe heterosexual sex in African countries because there is no evidence that levels of unsafe heterosexual sex there are high enough; and secondly, it is unlikely that HIV is rarely transmitted through unsafe medical procedures and other possible blood-borne routes. Conditions in African medical facilities are poor, just as they are in many Asian medical facilities.

In fact, in African countries where many people have (or at one time had) access to medical facilities, HIV rates are the highest in the world: South Africa, Zimbabwe, Swaziland, Lesotho, Botswana and others. In countries where many people have little or no access to medical facilities, HIV rates are far lower. For example, Kenya, Uganda and Tanzania, especially the rural parts of these countries. And in almost all areas with high HIV prevalence, more women than men are infected, often far more women.

So UNAIDS and the HIV industry have spent years tying themselves in knots trying to explain why a disease that is both sexually transmitted and blood-borne is mainly sexually transmitted in some countries and mainly blood-borne in others. This is especially difficult when neither levels of sexual behaviour nor conditions in medical facilities bear out such a conclusion. But if you supplant evidence with prejudice in developing a health strategy, you are bound to end up with such anomalies.

This sort of institutional racism results in the rather obtuse view that Africans engage in inordinately high levels of sexual activity, despite evidence to the contrary. HIV prevalence has reached hyperendemic levels in many Southern African countries, so the HIV industry insists on sexual behaviour change. Why these racists have also concluded that virtually no HIV transmission occurs as a result of unsafe medical practices is a complete mystery. But as a result, the industry feels that no effort need be made to improve conditions in medical facilities.

HIV, which is difficult to spread sexually, quickly spread to every country in the world throughout the 80s and 90s. In most countries, prevalence has remained below 1%. But in some countries, over 25% of sexually active adults are infected. No adequate explanation has been given as to how this could happen if HIV is mainly sexually transmitted. On the other hand, there have been several outbreaks of medically transmitted HIV (that have been properly investigated. In addition to Romania, there were also outbreaks in Libya, Kazakhstan and Russia that were caused by unsafe healthcare). The combination of sexual and blood-borne infection could help explain how these hyperendemics occurred.

This is not a conclusion. All we can conclude is that non-sexually transmitted HIV plays some part in countries with high HIV prevalence. The part that non-sexual transmission plays may have been more significant in the past, certainly in countries that have had the capacity to improve medical and other facilities. But rates of HIV transmission in some hyperendemic countries are still too high to be explained by sexual transmission alone. This means that a lot of work needs to be done to ensure that medical facilities and other places where blood-borne risks exist are made safe.

But first, UNAIDS and the rest of the HIV industry need to agree to investigate the extent of non-sexual HIV transmission. They need to agree to prevention programs that target non-sexual transmission, in all its forms. Unless people are aware of the risks they face, they will not know that they need to avoid these risks, let alone know how to avoid them. Surely levels of institutional racism and sexism that allow millions of people to become infected with HIV and to die of Aids are serious enough to deserve the world’s attention?

Test All, Treat All for HIV: Just Another Shot in the Dark

The authors of an article entitled ‘HIV drugs for treatment, and for prevention’ write as if to ask why we would delay using antiretroviral (ARV) drugs for preventing, in addition to for treating HIV, when so much evidence points to the effectiveness of such a strategy. But their rhetoric could be interpreted another way. They and others in the HIV industry seem to be saying, in a tone of mounting desperation, “Look, nothing else has worked so far, let’s try it until something else comes along”. In a list of failed possibilities including condoms, behaviour change of various kinds, circumcision, vaccines, microbicides and treating other sexually transmitted infections (STI), something else probably will come along. Whether that something will also fail remains to be seen.

The authors may object that some of those possibilities have not failed, for example, circumcision. Well, results of circumcision trials and even large scale circumcision rollout are shrouded in controversy but in Kenya, the only place where substantial numbers have been circumcised, the issue is far from resolved. And the biggest worry for some people is that Kenya does not have adequate health facilities to rollout any widespread programme safely. Aside from that, some worry that the program is being rolled out before its effectiveness has been adequately demonstrated. Maybe circumcision can help in areas where levels are currently low but this is by no means clear.

The effectiveness of condoms, also, is not as clear as one might expect. The latest results from the Kenya Demographic and Health Survey, 2008-09, suggests that people using condoms are often more likely to be HIV positive. It’s not certain why this is so and people would be unwise to give up using condoms, but a major problem with condoms and contraception in general in some countries, Uganda, for example, is availability and accessibility. The Kenyan DHS report, along with many other DHS reports, also cast doubt on the value of various behaviour change campaigns. Behaviour often doesn’t change, for various reasons. But even where it does, this doesn’t seem to have much impact on HIV transmission.

Testing everyone for HIV and treating everyone found to be HIV positive, the strategy advocated by the authors in question, may well have its virtues. If it’s possible to test everyone in every country that has high HIV prevalence regularly, perhaps every year, that would be a good start. Then, being able to treat all of them, for the rest of their lives, would also be required. Mathematical models have shown, apparently, that if such massive numbers of people could be tested regularly and then treated for the rest of their lives this would, under optimal conditions, quickly eradicate HIV (although not all models are in agreement). All we have to do is ensure optimal conditions.

Uganda doesn’t currently have optimal conditions for such a strategy, nor does any other high prevalence country. Testing is slow, many have never been tested, others return for testing more than once but most don’t. There is even an unmet demand for testing which may take some time to meet, given the country’s poor infrastructure and health network. Condom distribution is failed by a stop-start supply and contraception more generally suffers from similar problems, despite family planning being pursued in the country for several decades before HIV was recognised.

In fact, the country’s reasonably modest aim, to treat all HIV positive people who have reached a specific stage of disease progression, is not being met either. Drugs often don’t reach their destination or arive too late. Some remain in storage, even until they have expired, because of lack of infrastructure and health systems. Funding for ARV treatment comes exclusively from external donors. And these donors are talking about reducing funding substantially, some have already done so. An important question is not just about whether these conditions will be changed but would it really be possible to successfully implement a strategy like ‘test and treat’? Does the country’s performance over the past 25 years suggest that it would be possible?

The results of trials that show that HIV transmission is very low when people are on ARV treatment seem impressive. But a universal ‘test and treat’ programme would be, presumably, rolled out under the same conditions as previous HIV prevention programmes. Or maybe the latest one will be rolled out under optimal conditions? Maybe health institutions, infrastructures, education and other social services will be improved to the extent that this test and treat programme will work. It seems likely that HIV transmission would reduce somewhat without a test and treat programme under these conditions. At least it would be a possibility, however surplus to requirements it may become.

But there is still the same worry about this and all the failed or failing programmes that went before: shouldn’t we be frank about what we know and don’t know about HIV transmission, especially the extent to which HIV is sexually transmitted? We know HIV is not always transmitted sexually, but the HIV industry is very coy about admitting the extent of non-sexual transmission. And all the programmes listed above presuppose sexual transmission of HIV, whether they involve vaccines, microbicides, condoms, behaviour change, circumcision, STI treatment or a selection of these combined. Maybe test and treat is different, perhaps it will also reduce non-sexual HIV transmission. But it won’t, on its own, alter the circumstances that result in non-sexual transmission. Rolling out a disease prevention programme that is indifferent as to how that disease is spread seems foolhardy.

Unmixed Messages Could Scupper World Cup ‘Opportunity’

It's all about taking part, not winning, right? It’s certainly not about corporate domination, making money or anything so sordid. The World Cup probably means different things to those who care, can afford it or have something to gain from it. But there seems to be a worry that warnings about public safety could detract from people’s enjoyment of the football. According to the British Guardian, Fifa are blocking attempts to distribute condoms at venues. Fifa deny this and say no attempts have been made to set up condom distribution facilities. But even safe sex information has been banned, apparently.

I imagine people from Western countries travelling to South Africa will receive plenty of information about safe sex before they leave their own safe countries. Many will probably have their own supply of condoms or be able to buy them on arrival. They may even receive information on other HIV risks, such as from medical and cosmetic treatment.

They may be told that some health providers have a shortage of equipment and trained personnel, so they have to make sure that needles, syringes, suture needles and other equipment are properly sterilised if they haven’t taken a supply of medical equipment with them. It’s possible that visitors will also be warned to avoid getting tattoos, body or ear piercings or any cosmetic treatment that breaks the skin. (I’ve seen a warning about avoiding tattoos because they may be regretted later but none about the risk of HIV or any other disease.) Condoms are great for preventing sexual transmission, but I think people will need information about more than just basic safe sex.

Some Aids organizations are said to see the World Cup as a good opportunity to give out messages about HIV. But which messages are they trying to give out? That HIV is sexually transmitted? Report after report has shown that most people in African countries already know that. Whether people from Western countries know that or see that as relevant to them is another matter. But when will Aids organizations start to warn people about non-sexual risk of HIV? Non-sexual risks, especially from medical treatment, have been recognised since the early 1980s, almost since HIV was identified as the virus that caused Aids. But since early on in the epidemic, international health institutions have remained relatively silent about this important mode of infection. It is rarely discussed and every year these institutions publish figures purporting to show that medical transmission is very low and hardly worth worrying about.

Hospitals in South Africa are generally in poor condition, places you would not visit for treatment unless you really had to. Most South Africans really have to put up with these conditions, but rich South Africans (and rich visitors) don’t. They can opt for the expensive and hopefully safer hospitals, such as the ones that are looking for health tourists during the World Cup. Even those World Cup fans who need routine accident and emergency treatment will probably opt for something a bit better than the facilities available to poor South Africans. If Aids organisations see the World Cup as an opportunity to get a message across, that message should be relevant to everyone, regardless of their race, economic circumstances or any other criterion.

It is clear that HIV is transmitted by routes other than sexual behaviour. It is also clear than non-sexual transmission is far higher than UNAIDS and others will admit. Just how high non-sexual transmission goes in African countries is unclear because outbreaks of medically transmitted HIV have, so far, been entirely uninvestigated. UNAIDS is happy to warn UN employees to avoid medical treatment in African countries, except in UN approved hospitals. But they don’t seem to want Africans to know about the risks of medically (and cosmetically) transmitted HIV. This is the message that needs to be broadcast during the World Cup. Why the sudden worry that a few Westerners will become infected with HIV when Africans are being infected every day and much of this transmission could be avoided?

A brief article about preparations for medical emergencies during the World Cup mentions the ‘beleaguered health system’ and the huge HIV epidemic, but says nothing about the risk of medical transmission of HIV. The country is not suddenly going to acquire the capacity to provide adequate and safe medical treatment for everyone, no matter how important the World Cup is perceived to be. But that is part of the important message that Aids organizations should be concentrating on: that people should be aware of all the risks and how to protect themselves in order to avoid HIV and other diseases. The warnings should no longer be just about sexual risk but should include non-sexual risks too, especially risks of medical transmission.

The sort of racism that gives rise to UNAIDS and other institutions claiming that HIV is mostly transmitted by heterosexual sex in African countries results in an overemphasis on sexual risk and little or no emphasis on medical transmission. But another instance of racism seems to come out in the run up to the World Cup. There seems to be a lot more concern about non-Africans becoming infected with HIV than about Africans, who face risks, sexual and non-sexual, every day. They have faced these risks for decades and it looks as if they will continue to do so for decades. Apartheid may have ended, nominally. But every African, as well as every non-African, needs to be aware of how to avoid HIV infection and everyone needs access to information and facilities that will protect them. These are not yet available: that is why around 1,400 South Africans become infected with HIV ever day. HIV risk didn’t start with the World Cup and it won’t end with there. But it looks as if the usual Aids organisations will waste the opportunity by talking exclusively about sexual risk, yet again.